Barriers to accessing and providing rehabilitation after a lower limb amputation in Sierra Leone - a multidisciplinary patient and service provider perspective

Factors influencing access to and participation in rehabilitation for people with lower limb amputation in East, South, and Southeast Asian developing countries: the perspective of rehabilitation professionals - a qualitative study

PURPOSE

To identify barriers and enablers for access to and participation in rehabilitation for people with LLA in East, South, and Southeast Asian developing countries from the perspective of rehabilitation professionals.

MATERIAL AND METHODS

A mixed-method study involving an anonymous cross-sectional screening survey followed by in-depth interviews of rehabilitation professionals in these regions following the COREQ guidelines. Participants were surveyed online using convenience and snowball sampling techniques to inform a purposive heterogenic sample for semi-structured online interviews, between September 2021 to February 2022. Interview transcripts were analysed and thematically coded using the modified Health Care Delivery System Approach (HCDSA) framework.

RESULTS

A total of 201 quantitative survey responses shaped the interview questions and participation of 28 participants from 13 countries for the qualitative investigation. Important factors at the patient level were sex, economics, health issues, language differences, and lack of awareness; at the care team level, peer and/or family support, referrals, and the gender of the professional; at the organizational level, service availability, resources, and quality; and at the environmental level, policies, supports, and physical and/or social accessibility.

CONCLUSIONS

Identified interlinked factors at multiple levels of the HCDSA underpin the need for a systems approach to develop and address regional rehabilitation service provision but requires contextually adapted policy.

Assessment of activities and participation of people by rehabilitation-focused clinical registries: a systematic scoping review

INTRODUCTION

Rehabilitation is considered a key intervention in health care. Clinical registries, defined as an organized system that uses observational methods to collect information to assess specific outcomes in a defined population, can contribute to assessing the impact of the rehabilitation intervention. This review aims to identify and describe rehabilitation-specific registry systems with an emphasis on identifying outcomes that enable the assessment of vital areas and activities of daily living.

EVIDENCE ACQUISITION

A systematic scoping review was conducted. A systematic search was conducted up to August 2022 in MEDLINE/PubMed, Embase, Cochrane Library, Epistemonikos, and other search resources. Studies related to rehabilitation registries presented data on people with health problems that could limit their functioning were selected. The inclusion of studies/clinical registries was not limited by methodological design, year of publication, country, or language. The unit of analysis was rehabilitation registries. The measurement instruments used to assess the outcomes were explored to estimate the domain assessed from the vital areas related to functioning and disability as described by the International Classification of Functioning, Disability and Health (ICF). The vital areas were classified according to activities of daily living (ADLs).

EVIDENCE SYNTHESIS

Seventy-one registries in rehabilitation were identified. The registries included a median of 3 (IQR 2-5) assessment instruments designed to assess the impact of different rehabilitation programs. In total, 137 different assessment scales or instruments were identified. Each rehabilitation registry assessed 6 (IQR 2-8) domains of the ICF, and 15.4% of registries assessed all domains. The most assessed domain was "Mobility" (89.7%), and the least assessed was "General Tasks and Demands" (25.6%). In addition, 92.3% of rehabilitation registries assessed basic ADLs, 76.9% advanced ADLs, and 71.8% instrumental ADLs.

CONCLUSIONS

Although clinical registries do not claim to directly assess the impact of rehabilitation programs on people's functioning according to the ICF framework, it was identified that a low percentage of them assessed the nine vital areas through different outcome assessment instruments. However, most rehabilitation registries directly or indirectly assess some basic, instrumental, and advanced ADLs. The findings of this review highlight the need to improve the design of clinical registries focused on assessing the impact of rehabilitation programs to assess people in all areas of their lives.

Transfemoral amputation and prosthesis provision in Tanzania: Patient and provider perspectives

Background

The burden of disability because of traumatic limb amputation, particularly transfemoral amputation (TFA) is disproportionately carried by low- and middle-income countries. The need for improved access to prosthesis services in these settings is well-documented, but perspectives on the burden imposed by TFA and the challenges associated with subsequent prosthesis provision vary among patients, caregivers and healthcare providers.

Objectives

To examine the burden of TFA and barriers to prosthesis provision as perceived by patient, caregiver and healthcare professional, at a single tertiary referral hospital in Tanzania.

Method

Data were collected from five patients with TFA and four caregivers recruited via convenience sampling, in addition to 11 purposively sampled healthcare providers. All participants participated in in-depth interviews regarding their perceptions of amputation, prostheses and underlying barriers to improving care for persons with TFA in Tanzania. A coding schema and thematic framework were established from interviews using inductive thematic analysis.

Results

All participants noted financial and psychosocial burdens of amputation, and perceived prostheses as an opportunity for return to normality and independence. Patients worried about prosthesis longevity. Healthcare providers noted significant obstacles to prosthesis provision, including infrastructural and environmental barriers, limited access to prosthetic services, mismatched patient expectations and inadequate coordination of care.

Conclusion

This qualitative analysis identifies factors influencing prosthesis-related care for patients with TFA in Tanzania which are lacking in the literature. Persons with TFA and their caregivers experience numerous hardships exacerbated by limited financial, social and institutional support.

Contribution

This qualitative analysis informs future directions for research into improving prosthesis-related care for patients with TFA in Tanzania.

Rehabilitation professionals' perspectives of factors influencing return to occupation for people with lower limb amputation in East, South, and Southeast Asian developing countries: A qualitative study

Objective

To identify barriers and enablers for return to occupation (RTO) for people with lower limb amputation (LLA) in East, South, and Southeast Asian developing countries from the perspective of rehabilitation professionals.

Methods

A convenience sample of rehabilitation professionals working in Asian developing countries participated in online in-depth interviews between September 2021 and February 2022. Interview transcripts were analyzed and thematically coded to the modified Health Care Delivery System Approach (HCDSA) framework. COREQ guidelines were followed.

Results

Twenty-eight interviewees from 13 countries shared their experiences of factors related to RTO for people with LLA. Identified factors described barriers and facilitators for RTO at all four HCDSA framework levels. The "environmental" level had the most identified factors (n = 56) and the "care team" level the least (n = 31). Common environmental RTO challenges included cultural attitudes to women; lack of rural/remote services; inadequate numbers and regulation of rehabilitation professionals; inappropriate prosthesis; limited government support for rehabilitation, and reliance on charitable models.

Conclusions

Despite varied cultural, religious, and geographical characteristics, consistent factors impacting RTO were identified within these thirteen countries. Identified barriers to RTO underline the need for improvements throughout service systems from the acute-care focus on saving life without consideration of RTO, the rehabilitation focused primarily on mobility, to the lack of occupational rehabilitation services and supporting policy in these countries. These interlinked factors at different levels of healthcare service systems reinforce the importance of systems approaches to best utilize limited resources toward improving RTO in this region.

Influential factors for access to and participation in rehabilitation for people with lower limb amputation in East, South, and Southeast Asian developing countries: a scoping review

PURPOSE

To explore factors impacting access to and participation in rehabilitation for people with lower limb amputation (LLA) in East, South, and Southeast Asian developing countries.

MATERIALS AND METHODS

A scoping review was undertaken following the PRISMA-ScR guidelines. Five electronic databases (PsycINFO (Ovid), Medline (Ovid), CINAHL (EBSCO), AMED, and Proquest Social Sciences) were searched for articles from January 1980 till March 2020. Two authors independently assessed articles for inclusion. Included articles were classified according to the Health Care Delivery System Approach (HCDSA) framework levels.

RESULTS

Twenty-four studies from 14 countries were identified. At patient level, age, gender, limited rehabilitation awareness, and economic status; at the rehabilitation level, gaps in referrals, family support, and professional skills; at the environmental level, services availability, and location; and, at government level, service costs, income loss, and lack of supporting policies were identified as important influencing factors.

CONCLUSIONS

Rehabilitation access and participation factors were identified at multiple levels of the HCDSA. Contextually appropriate and accessible services considering individual characteristics and socio-economic status of individuals with LLA are needed, with timely referral to rehabilitation by trained professionals. Improving rehabilitation services for people with LLA in Asian developing countries requires supportive environments, accessible transport, social and financial security, and increased awareness, underpinned by appropriate policy.Implications for rehabilitationProvision of timely referral to rehabilitation by primary/acute health care settings with involvement of family/peer supports.Improved government support systems to facilitate individual access to and participation in rehabilitation with consideration of contextual socio-demographic and economic factors.Prioritisation of adequately resourced and well-designed rehabilitation centres by health care organisations in accessible locations.Implementation by local government of strategies to support development and implementation of well resourced, accessible, equitable, and contextually responsive rehabilitation services.

Learning about the changing needs for prosthetics service provision from routinely collected digital centre management data: An exemplar study across three clinics in Cambodia

Background

Prosthetic service development and delivery rely on data describing population needs. These needs are context-specific, but most existing data come from high-income countries or small geographic areas, which are often not comparable. This study analysed routinely collected digital patient record data at multiple time points to provide insights into characteristics of people accessing Cambodian prosthetic services.

Methods

We investigated trends in birth year, sex, year and reason for limb absence, and prosthesis type, over three decades. Then, we observed data from 2005 and 2019 indicating how the population actively accessing prosthetics services has changed.

Results

Temporal trends in prosthetics service user demographics corresponded with events in Cambodia’s socio-political history. The predominant historical reason for limb absence prior to 2000 was weapon trauma during and following conflict. Since 2000, this was replaced by non-communicable disease and road accidents. Transtibial remained the most prevalent amputation level but transfemoral amputation had higher incidence for people with limb loss from road accidents, and people with limb loss due to disease were older. These observations are important as both transfemoral and older-aged groups experience particular rehabilitation challenges compared to the young, transtibial group.

Conclusions

The study shows how standardised, routinely collected data across multiple clinics within a country can be used to characterise prosthetics service user populations and shows significant changes over time. This indicates the need to track client characteristics and provides evidence for adapting services according to population dynamics and changes in patient need.

Access to health and rehabilitation services for persons with disabilities in Sierra Leone - focus group discussions with stakeholders

Background

In Sierra Leone persons with disabilities are at higher risk of living in poverty and have poor access to a fragile healthcare and rehabilitation services. The aim was to explore stakeholders’ perceptions of access to health and rehabilitation services for persons with disabilities in Sierra Leone.

Methods

Seven focus group discussions, including stakeholders working within the field of disability was conducted.

Results

The subthemes were: continuous stigmatisation of persons with disabilities throughout life; long distances and transportation issues to access health and rehabilitation facilities; financial constraints; infrastructural barriers to healthcare and rehabilitation services and healthcare personnel’s negative attitudes and inadequate knowledge towards persons with disabilities; rehabilitation and healthcare facilities lacking materials to provide quality services; lack of specialised services and rehabilitation personnel for complex rehabilitation and the need for continuous education of new and current rehabilitation personnel.

Conclusion

Local actors need to take charge and renew efforts made by international organisations by providing trained rehabilitation staff and quality rehabilitation services. Rehabilitation services need to be affordable and transportation costs covered for persons with disabilities to access healthcare and rehabilitation services. Continuous education of the public and health personnel about disability is necessary to reduce negative attitudes towards persons with disabilities.

Pioneering low-cost 3D-printed transtibial prosthetics to serve a rural population in Sierra Leone - an observational cohort study

BACKGROUND

There is a huge unmet global need for affordable prostheses. Amputations often happen in Sierra Leone due to serious infections, complex wounds, traffic accidents and delayed patient presentation to the hospital. However, purchasing a prosthesis is still beyond reach for most Sierra Leonean amputees.

METHOD

We applied computer-aided design (CAD) and computer-aided manufacturing (CAM) to produce low-cost transtibial prosthetic sockets. In February and March 2020, eight participants received a 3D printed transtibial prosthesis in the village of Masanga in Tonkolili district, Sierra Leone. Research was performed using questionnaires to investigate the use, participants' satisfaction, and possible complications related to the prostheses. Questionnaires were conducted prior to production of the prosthesis and five to six weeks after fitting the prosthesis. A personal short-term goal was set by the participants.

FINDINGS

Competitively priced and fully functional prostheses were produced locally. After six weeks, all participants were still wearing the prosthesis and six of the eight participants reached their personal rehabilitation goals. Using their prostheses, all participants were no longer in need of their crutches.

INTERPRETATION

We have come a step closer to the production of low-cost prostheses for low-and middle-income countries (LMICs). The goal of our project is to perform long-term follow-up and to refine our concept of 3D printed prostheses for LMICs to provide practical solutions for a global health need unmet to date.

FUNDING

€ 15,000 was collected during a crowdfunding campaign in collaboration with the Dutch Albert Schweitzer Fund. Internship allowance for MvdS was obtained from the University of Twente. 3D-scanner, 3D-printer, and printing material were donated by Ultimaker BV and Shining 3D.

The lived experience of people who require prostheses or orthoses in the Kingdom of Cambodia: A qualitative study

BACKGROUND

There is an assumption that provision of assistive technologies, such as prostheses and orthoses, will improve the life situation of people with disabilities; however, this issue has been poorly addressed in low- and middle-income country settings.

OBJECTIVE

The objective of this qualitative study was to explore the life experience of people who use lower-limb prosthetic or orthotic devices in Cambodia, with a view to identifying areas in which developments can be made to improve the life experiences for prosthesis and orthosis users.

METHODS

Participants were recruited from 1/urban and 2/rural prosthetic and orthotic clinics, run by the same non-governmental organisation. Individual interviews were conducted in 2019 with 15 users of prosthetic or orthotic devices. Interviews were transcribed and analysed using a thematic analysis approach.

RESULTS

Three themes were identified: 1) A more positive outlook with an assistive device; 2) assistive devices reduce barriers but do not eliminate them and 3) disability creates social exclusion while assistive devices facilitate inclusion. For participants in this study, life without a prosthesis or orthosis was characterised by financial insecurity and a sense of hopelessness. After receiving an assistive device, participants experienced a greater sense of self-worth and empowerment as well as improved functional performance and social interactions.

CONCLUSIONS

Disability was found to affect multiple facets of participants' lives including physical and psychosocial factors. Prosthetic and orthotic devices were experienced as being enablers of social inclusion and generally improved the life situation for individuals with disabilities in The Kingdom of Cambodia. Attention should be directed towards improving knowledge of, and access to prosthetic and orthotic services, securing a stable income for users and addressing device related problems.